From the 330 invited GPs, 25 GPs expressed an interest in participating, though only nine actually did so. The reasons given by the 16 who did not show up were: "lack of time" and "distance of travel to the FG". The other 305 did not reply. Sociodemographic characteristics of participating GPs are shown in table
2.
Table 2
Characteristics of GP focus groups (n = 9)
sex female/male | 3/6 |
age; mean (SD); range | 53.88 (6.05); 47-67 |
office based since; mean (SD); range | 20.55 (6.54); 16-36 |
single handed practice | 5 |
group practice | 4 |
located: city | 2 |
located: outskirts | 5 |
located: countryside | 2 |
Translation
The process of translation and consensus resulted in an accepted version of the translated ACIC. There were difficulties in understanding the exact meaning of some items of the translated ACIC. This was, apart from the differences in both healthcare systems, due to a lack of understanding of the CCM and an ambiguous phrasing of the items which were not precise enough in German. Furthermore, some of the concepts of the ACIC seemed not as relevant to German healthcare settings.
From the six elements of the CCM, items from "clinical information system", "community linkage" and especially "self management support", were less difficult to understand by the translation team. Whereas items relating to "organization of healthcare delivery system", "decision support" and "delivery system design" were more difficult to understand and to apply to German healthcare settings.
One example of a multifaceted understanding of words was: "Community Linkages". The word "community" is very imprecise as in German it can mean municipality, association or alliance. Therefore this entire part of the ACIC can be understood in many different ways.
A further example is in "Organization of the Healthcare Delivery System": The first ACIC item concerning the overall Organizational Leadership in Chronic Illness Care says at "C level" "(...) is reflected in vision statements and business plans, but no resources are specifically earmarked to execute the work."
Our translation group did not understand how "business plans" fits in this context.
What we learned after asking the authors at the MacColl Institute was that healthcare organizations in the USA must support the changes financially at the planning level.
The conclusion of this procedure was that a translated ACIC can not easily be completed by respondents. As such, we had to revise our strategy for its cultural adaptation and the back translation was not performed. We decided to build a completely new questionnaire. The main domains of the consensus version of the ACIC instrument formed one basis of a new questionnaire entitled "Questionnaire of Chronic Illness Care in Primary Care" (QCPC). This entirely new questionnaire consists of relevant aspects of the CCM: Delivery system (12 questions), community linkage (5 questions), self management support (6 questions), decision support (7 questions) and clinical information system (5 questions). Furthermore the QCPC includes socio demographic questions and aspects of chronic illness care relevant to Germany such as structure of practices (23 questions), quality management (3 questions) and disease management programs (2 questions). From our experiences with difficulties in using the ACIC instrument in a different healthcare system, we did not include questions regarding Organisation of healthcare delivery system in the QCPC. For further details regarding differences with the ACIC please see table
3.
Table 3
Differences ACIC and QCPC
Organization of healthcare delivery system | 6 | 0 |
Community linkages | 3 | 5 |
Self management support | 4 | 6 |
Delivery system | 6 | 12 |
Decision support | 4 | 7 |
Clinical information system | 5 | 5 |
Categories of Answer
| ACIC | QCPC |
| Scores: D Level (0-1) up to A Level (9-11) resulting in a sum score as well as score for the single CCM component used for quality improvement programs. | Five-point-Likert scale e.g. using "always" to "never" or percentage as well as yes/no answers resulting in a tailored feedback of the single practice used for improvement of chronic illness care. |
Directions
| ACIC | QCPC |
| Can be filled out by anyone of one physical site (e.g., a practice, clinic, hospital, health plan) that supports care for chronic illness (condition has to be specified). | Should only be filled out by a primary care physician who supports care for patients with chronic illnesses (condition has not to be specified). |
As this new questionnaire had to be built, the types of answers to ACIC are different, too. New items were developed according to the rules of questionnaire design by Porst [
21].
Focus groups (FG) were now asked to comment on items of QCPC instead of ACIC. Items concerning the CCM were integrated as close to its original version as possible. Categories of answers were changed into yes/no or Likert scales.
Focus groups
In the FG some items with a CCM background, were not considered to be important. Example referring to "Delivery System Design"
Physicians saw no need for a system to track patients if they went to an appointment by a specialist or not, or if they got a report or not.
"(...) you would need to know, if your chronically ill patient is already discharged, or still in hospital. (...) to follow up results I would need to know if my patient is at hospital at all." (P3)
Example referring to "Decision Support"
Using guidelines was considered to be more like an "add on", something physicians have in mind when treating patients, rather than following guidelines strictly.
"I notice every guideline in an informative way, I save it in my head, but I will not actually go get the guideline and look something up. (...) I only need it sometimes as an excuse if something happens, meaning recourse, medical recourse or something." (P5)